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Rural Success with Housing First
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Pathways Vermont is demonstrating that Housing First can have the same success rate in a rural area as it does in urban areas. Executive Director Hilary Melton, who has been working with this model since the 1980s, shares how creative use of tele-health and a commitment to providing everyone they serve with a home and intensive services is the key to their success.



In the 1980s Hilary Melton was conducting street outreach in Boston for the Pine Street Inn. Shortly thereafter she moved to New York City to study poetry and work at a drop-in center. The poetry workshop Hilary participated in coincided with her work on the street. As she was reaching out, Hilary was also reaching in. “The connection between the two is that I am an incest survivor and my journey to healing included poetry and writing. I had to write about it.” Many of her colleagues also entering the field seemed to be on a healing path—the walking wounded—trying to find their way. Her favorite poets at the time included E.E. Cummings, “not even the rain has such small hands…” and Franz Wright.

And in New York is where she met Dr. Sam Tsemberis, which led to her becoming the first Director of the first Housing First program at Pathways to Housing in 1992. “We were a small team. We housed people directly from the street and tried to eliminate the barriers they faced; that was our goal,” says Hilary. “We were mavericks and we had Sam Tsemberis leading the way. We believed in people. Even today that magic is within us.” The experience of working with Sam in the program reflected Hillary’s own feelings of liberation with her writing: “When a person doesn’t have to fill out a form, expose their secrets, or spill their life bare, this is liberation. No one should have to prove anything. Just because you have a diagnosed mental illness does not mean you should have to prove yourself.”

Hilary is now the Executive Director of Pathways Vermont, which operates a rural Housing First project under an umbrella of the larger Housing First project. Hilary credits Patrick Flood, Commissioner of the Vermont Department of Mental Health, calling him a visionary thinker who is committed to making mental health care accessible to everyone in Vermont. Pathways Vermont has funding from SAMHSA for the SSH First Rural Demonstration Grant and a CABHI Grant. In addition, Pathways Vermont is working in collaboration with the Vermont Department of Mental Health on the Mental Health Transformation Grant.

Housing First has shown high retention rates in urban settings, where there are more opportunities for switching apartments when concerns arise. A rural setting presented new challenges. In a rural area, the community is tight-knit and there are fewer housing options. The Housing First model is traditionally accompanied with Assertive Community Treatment (ACT). This is both intensive and expensive so, in a state like Vermont, with excessive inclement weather and challenging transportation, the challenge was, how could they provide these services on limited budgets?

Under Hilary’s leadership over the last two and a half years, Pathways Vermont has housed 138 people across five counties with an 85 percent retention rate, which matches the urban model. Housing stock is low, but 15 percent of the program’s employees are dedicated to housing support and are working closely with sixty landlords. Pathways Vermont has a total of 30 staff, 24 of whom are full-time. They use a hybrid model for the ACT team, switching to local service coordinators, and a regional team of specialists including nurses, a psychiatrist, a digital literacy specialist, and a peer support specialist.

One of the keys to reaching everyone who is housed is the utilization of technology and a tele-health program that is connected with the five counties engaged in the program. All tenants who are interested are given refurbished computers, webcams, headsets, internet access, and Gmail and Facebook accounts. They are able to connect with service coordinators and psychiatrists. Hilary attends five to ten meetings a week with colleagues throughout the state via videoconferencing. Tele-health care has been a new culture shift, a new practice, and a successful one.

While the technology is essential for a rural area, at the core of Housing First is a philosophy that starts with the individual and relationship building. Like Hilary’s own experience of healing through poetry, she has walked alongside so many who have experienced healing through housing. Service providers are excellent problem solvers with fine skills, but the practice of Housing First is to let people see what their goals and dreams are as they build the muscles of self-esteem. Pathways practices every day to stay out of the way of that essential work. “It is a basic right to have a home,” says Hilary. “It is so important that the people we are building relationships with define what kind of help they want and remain in charge of that. To not practice this is counter intuitive.”

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